Provider Demographics
NPI:1831554674
Name:BROADWAY DETOX CENTER LLC
Entity type:Organization
Organization Name:BROADWAY DETOX CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:LENNERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-655-0948
Mailing Address - Street 1:18582 BEACH BLVD
Mailing Address - Street 2:STE 214
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-2000
Mailing Address - Country:US
Mailing Address - Phone:714-655-0948
Mailing Address - Fax:
Practice Address - Street 1:6021 JADE CIR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-2246
Practice Address - Country:US
Practice Address - Phone:714-655-0948
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility